Eliminating untimely deaths of women from heart disease: Highlights ...

Results of Expert Meetings

Eliminating untimely deaths of women from heart disease: Highlights from the Minnesota Women's Heart Summit Ruth Lindquist, PhD, a,b,c Jackie L. Boucher, MS, RD, b Elizabeth Zane Grey, MD, a Beth Cairns, MA, RN, a Shalini Bobra, MD, a Denise Windenburg, BS, c Suma Konety, MD, c Kevin Graham, MD, a Russell Luepker, MS, MD, c and Sharonne N. Hayes, MD d Minneapolis, and Rochester, MN

Despite national campaigns to increase awareness and reduce cardiovascular disease (CVD) mortality in women, CVD remains their leading cause of death, annually killing more women than men. Although some progress has been made in our understanding and treatment of CVD in women, the causes, extent, and demographic trends of observed sex differences and disparities remain uncertain, and the growing burden of CVD and its risk factors among younger women is concerning. The Minnesota Women's Heart Summit was convened to chart a course to eliminate premature deaths of women from heart disease. The multidisciplinary summit was hosted by the Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, University of Minnesota, and Mayo Clinic. Presentations highlighted sex-based differences in symptoms, treatment, and outcomes, and panel experts provided commentary. Invited faculty and summit participants worked in small-group sessions to identify strategies to dissolve barriers, improve primary and secondary prevention, and enhance women's care and outcomes. This report summarizes strategies identified during the conference to serve as springboards for more substantive future initiatives. These include, for example, standardized data collection and use of existing data sets to inform perspectives on sexrelated cardiovascular issues, mandatory reporting of sex-specific data, and increased attention to underserved/high-risk women. Participants acknowledged that implementing these ideas would be challenging and recommended key priorities/next action steps such as providing services close to “point-of-life” rather than “point-of-care” and creation of policies and regulations so that resources and environmental modifications encouraging healthier lifestyle choices are promoted. Additional research is needed to improve identification, treatment, and health behaviors and to address continued lack of awareness, symptom recognition delays, barriers to care, and outcome disparities—especially in diverse populations. (Am Heart J 2012;163:39-48.e1.)

Cardiovascular disease (CVD) has been the leading cause of death of US women for many decades; in each year since 1984, total CVD mortality in women has exceeded that of men. 1,2 Although there have been substantial declines in total CVD mortality during the past several decades, women have not fully benefited from the advances in cardiovascular diagnosis and treatments that have contributed to these survival gains until recently. In fact, up until 2005, CVD mortality in women continued to rise despite steep declines for men. From the aWomen's Heart Health Program of Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, bMinneapolis Heart Institute Foundation, Minneapolis, MN, cUniversity of Minnesota, Minneapolis, MN, and dMayo Clinic, Rochester, MN. Submitted June 14, 2011; accepted September 26, 2011. Reprint requests: Jackie L. Boucher, MS, RD, Education, Minneapolis Heart Institute Foundation, 920 East 28th Street, Minneapolis, MN 55407. E-mail: [email protected] 0002-8703/$ - see front matter © 2012, Mosby, Inc. All rights reserved. doi:10.1016/j.ahj.2011.09.020

Recent signs suggest a reason for optimism. In each of the past 5 years, fewer women have died of heart disease as a result of both improved management of risk factors and improvements in medical therapy for heart disease. Results of surveys, public health campaigns, and increases in both research funding and scientific publications on women's cardiovascular issues suggest that clinicians, researchers, and the public have become increasingly aware of the presence and significance of important sex-related differences in all aspects of heart disease, 3 and efforts to include women in clinical research have increased information about women's health. 4 However, significant knowledge gaps remain, and disparities in health care delivery and health outcomes between women and men persist. Past observations of sex-based disparities in cardiovascular care and differences in morbidity, mortality, pathophysiology, symptoms, and the use and efficacy of therapeutic interventions have been well documented. Reported in the 1990s, women b50 years old were twice

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as likely to die after myocardial infarction (MI) 5 and 3 times more likely than men to die in the hospital after coronary artery bypass graft surgery. 6 The outcome and care gaps have narrowed in the past decade. Since 2000, death rates and cardiovascular events have shown downward trends in the United States, with women showing a similar or steeper decline compared with men. 7 In recent years, there has been a decline in hospital mortality after MI; however, women have experienced greater improvements relative to men. 8 Gender differences in treatment of heart failure and acute MI in 2 large national data sets were small or insignificant. Women underwent more percutaneous coronary intervention but less coronary artery bypass surgery. 9 Women and men share similar risk factors; however, there are important sex differences in both the relative impact of those risk factors and atherosclerotic processes and vascular physiology. 10 Across all age groups, women have been found to have less obstructive coronary artery disease than men when presenting with acute coronary syndrome (ACS), myocardial ischemia, or angina. 11 Women more commonly than men have MIs that present as apical ballooning syndrome and coronary artery dissection and are more likely than men to develop heart failure with normal systolic function. 12-14 The incompletely realized promise and unacceptably slow progress in reduction of heart disease deaths in women were the driving forces behind the Minnesota Women's Heart Summit, which brought together numerous disparate groups and individuals to focus on a singular goal.

The Women's Heart Summit To help chart future directions to improve the health outcomes of women with heart disease in Minnesota, the Minneapolis Heart Institute, the Minneapolis Heart Institute Foundation, the University of Minnesota, and the Mayo Clinic convened “Women and Heart Disease: A Summit to Eliminate Untimely Deaths in Women.” The 2-day summit was held in Minneapolis, MN, on April 29 to 30, 2010. The summit featured nationally known experts who identified unresolved challenges involving heart disease and women, panelists who stimulated discussion about solutions to the problems presented, and interactive breakout sessions that generated “bold next steps” from which follow-up actions could be taken. Attendees included public health researchers, nurses, cardiologists, dietitians, primary care physicians, health care administrators, clinical investigators, ancillary health professionals, and patients. Other key stakeholders included representatives from the Minnesota Department of Health; the National Heart, Lung, and Blood Institute (NHLBI); WomenHeart: The National Coalition for Women with Heart Disease; the American Heart Association (AHA); and several major health care payers.

The summit was supported by funding from the Women's Heart Health Program of the Minneapolis Heart Institute Foundation and the Minneapolis Heart Institute at Abbott Northwestern Hospital and through educational grants obtained from various companies designed to support continuing medical education programs (see listing in the online Appendix). The authors are solely responsible for this work, including the drafting and editing of the manuscript and its final contents.

Summit proceedings The summit focused on 4 key focus areas including (1) national community initiatives: building community awareness and prevention; (2) symptom recognition and delays in seeking treatment: clinical, physiological, and social factors; (3) closing the survival gap: sex differences and disparities in biology, pathophysiology, treatment, rehabilitation/follow-up care, and outcomes; and (4) patient-provider connections: challenges for women diagnosed with heart disease, including secondary prevention and ongoing disease management.

Focus area 1: community awareness and prevention Increasing community awareness is a promising strategy to reduce cardiovascular deaths among women; there are compelling population statistics and interventions in this area that have the potential for broad impact. The background statistics and current state of prevention and disease burden were reviewed. Stroke, heart disease, and other CVDs claimed the lives of 421,918 women in 2007—1 death per minute. One in 30 deaths in women is caused by breast cancer, whereas 1 in 6.4 is caused by heart disease, but most women still perceive breast cancer as women's number 1 health threat 15 and do not place as high a priority on prevention of and screening for heart disease as they do for cancer. 16 Knowledge among women about heart disease risk is improving, however. 3,16 Sequential surveys to evaluate trends in women's awareness, knowledge, and perceptions were conducted by the AHA from 1997 to 2009, and awareness of heart disease as the leading cause of death among women had increased from b20% to 57% in 2006 with no further gains in the 2009 survey (54%). Some of these gains can be attributed to the efforts and success of substantial public health campaigns such as the AHA's Go Red for Women campaign, NHLBI's The Heart Truth campaign, and outreach by WomenHeart Champions. 15 However, awareness is lower among African American and Hispanic women, and this racial/ethnic disparity has not changed appreciably over time. 17 In 2009, 54% of white women were aware that coronary heart disease (CHD) was the leading cause of death for women,

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whereas only 43% of Hispanic women and 44% of black women were aware. 3

Applying evidence-based research As many summit panelists and presenters noted, epidemics such as heart disease in women are not resolved by chance; efforts must be intentional to be successful. The North Karelia Project, implemented in the 1970s, was the first major community-based project for CHD prevention and was designed to address the record high CHD mortality in the North Karelia region of Finland. 18 The project was comprehensive and broad in scope and engaged individuals, businesses, government, schools, and the media. It effectively reduced CHD mortality in North Karelia by 80% over a 35-year period. 19 Many summit participants emphasized the need to initiate equally effective targeted primary and secondary prevention programs in the United States, using evidence obtained through the North Karelia Project and other successful communitywide heart disease prevention interventions. 20 Clearly identifying the specific elements contributing to the success of public health campaigns and prevention programs can ensure the continued effectiveness, optimal evolution, and proliferation of such programs. In addition to assessing improvements in awareness, knowledge, and lifestyle behaviors, evidence-based analyses should also explore the resources required to attain improved outcomes through primary and secondary prevention initiatives such as optimal program length, costs, and personnel. 21 Although sex-based differences in all aspects of CHD have been noted, few clinical trials enroll sufficient women to clarify the cause of these differences, and fewer still provide sex-specific reporting of results. 14,22,23 Summit participants reinforced the need for mandates to collect and report such data, to devise primary prevention programs that dramatically alter the state of women's heart health and the concomitant morbidity and mortality of women in the United States. Engaging clinicians, consumers, and policy makers Clinicians continue to underestimate the risks of heart disease in women. In a national study 24 of 500 physicians (including 300 primary care physicians, 100 obstetricians/gynecologists, and 100 cardiologists), b20% knew that more women than men die each year from CVD. Such misconceptions could explain why suboptimal recognition, diagnosis, and treatment of women's heart disease persist in the clinical setting. One challenge is to create targeted messages to reach underserved populations. For example, although Internet- or social media–based public awareness campaigns effectively and economically reach many women, depending solely on these approaches might fail to

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reach underserved, impoverished, or less-educated groups without access to requisite technologies. Because the immediate needs of underserved populations often include issues of unemployment, neighborhood violence, and other life stresses, it may be efficacious to embed primary heart disease prevention messages into already established public health campaigns created for these issues such as collaborative efforts within community violence prevention programs, unemployment centers, or cancer screening programs. It was noted that promotion of lifestyle modification is the core of many successful community-based prevention programs. This is particularly true of programs targeting women. Ninety-four percent of women's CHD risk can be attributed to potentially modifiable factors, including smoking, hypertension, abdominal obesity, alcohol consumption, lack of physical activity, inadequate intake of fruits and vegetables, psychosocial stress, and diabetes. 25 Important racial/ethnic disparities exist among women in behavior-related disease risk factors. 26 For example, Mexican Americans, American Indian/Alaskan natives, and blacks have been found across studies to have a higher prevalence of no leisure time activity relative to whites. Public health education campaigns have been shown to be effective in stimulating lifestyle changes in women. Women's awareness of CVD risks, through national awareness campaigns, has been linked to women taking action to reduce risks. 3 Women are encouraged to address their cardiovascular risk behaviors, as evident in the AHA's 2020 Impact Goal to focus on improving health factors and lifestyle behaviors. 27 In this campaign, women can assess their risk through answering online survey questions with the My Life Check tool then work to reduce their risk by adhering to “Life's Simple 7” health behaviors—foremost on this list is “not smoking.” The emphasis on smoking cessation and addressing nicotine dependence in women is critical. In 1 large national survey of women contacted through random digit dialing, women reported having taken numerous preventive actions: 71% had decreased their consumption of unhealthy foods, 63% increased their physical activity, 66% had their cholesterol monitored, 84% got their blood pressure checked, 73% saw their physician or health care provider, and 74% tried to manage their stress more effectively, whereas only 29% reported quitting smoking (25% white vs 38% nonwhite). 3 Importantly, barriers to these efforts are common, most notably when beneficial changes and initiatives are not supported or implemented broadly at the community level. Thus, creating effective public policy is the most important but often the most difficult aspect of ensuring the longevity of any public awareness or community-based heart disease prevention program. Efforts must identify and overcome obstacles in the context of the complex interactions among stakeholders

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and face the challenges inherent in making substantial changes to society's infrastructure (eg, clean indoor air acts that improve air but may be viewed by restaurateurs as adversely affecting business by disenfranchising their smoking customers; altering systems to increase availability and affordability of and access to fresh fruits and vegetables; reducing availability of energy-rich, processed food selections; modifying the built environment to promote physical activity; and improving health care access and providers' responsiveness to patients' concerns).

Focus area 2: symptom recognition and delays in seeking treatment The challenges and impact of women's cardiovascular symptom recognition and associated delays in accessing medical care were reviewed. Women's symptoms of MI and other ACS are often labeled “atypical” because they differ from the classic symptoms traditionally found in men, and this has been reported to be an important factor in the delay of women in seeking health care when experiencing ACS. 28 Research also indicates that women delay seeking treatment of MIs longer than men, in part because they may not experience chest pain or discomfort or believe that their constellation of symptoms are too different from the classic symptoms to warrant concern or medical attention. 29 Accurate recognition of the symptoms of ACS is crucial in both men and women because inaccuracies in symptom recognition may result in delayed treatment, which in turn may lead to more extensive myocardial necrosis and, consequently, a worse prognosis. Health care providers' lack of recognition of ACS/MI symptoms may also lead to incorrect diagnoses and delays in therapy. The strongest predictors of missed MI diagnoses—and of inappropriate emergency department discharges—are young age and the absence of chest discomfort. 30-32 In the mid 2000s, Canto et al 33 performed a metaanalysis of presenting symptoms of ACS/MI in women and men to determine whether sex-based differences in symptom presentation were significant enough to warrant sex-based public health messages for ACS symptom awareness. Approximately one third of male and female patients in the large cohort studies and 25% of those in the smaller studies presented without chest pain or discomfort, and the absence of chest pain or discomfort was more often noted in women than men. However, because these studies lacked standardized data collection, symptom reporting, and presentation of symptoms, the authors concluded that these differences were not significant enough to prompt a change in public health messages. From these results, the authors advised that “further research from well-designed clinical and


epidemiological studies must systematically investigate differences in the ACS/MI clinical presentation according to sex, age, and race, including separation of the chief complaint from more ancillary symptoms.” 33 To date, this has not been done.

Promoting standardization in research on symptoms Summit participants explored next steps for standardizing the characterization of ACS symptoms and for collecting data on women's symptoms in particular. Clinical trials for which certain symptoms comprise the entry criteria (eg, chest pain) by definition are not designed to allow evaluation of patients with atypical presentations, many of whom are women. The profile of participants ultimately mirrors the average male patient, and those without the index symptoms remain excluded from evaluation. Summit attendees concurred that studies must be designed to gather and distill standardized, evidencebased data on symptom presentation and recognition without requiring stringent homogeneity of the study populations to understand the symptom experience of both women and men and to allow opportunities for sexbased comparisons. This approach may help to answer 2 crucial questions: (1) do women have or experience heart disease symptoms different than men? and (2) how can we find, diagnose, and treat young women who have heart disease earlier and more effectively? Data generated by such studies could also be used to modify public awareness campaigns and provide more specific and definitive information regarding women's symptoms and prompt women to seek care if they experience them. Standardized data collection variables should go beyond sex-based factors to include race and age, at a minimum. Major professional organizations such as AHA should endorse a questionnaire form inclusive of standardized items, to promote their widespread adoption. Such standardized data collection, although initially focusing on ACS, also has the potential to address the full spectrum of ischemic heart disease, including but not limited to stable and unstable angina and heart failure. Implementing community-based symptom-recognition initiatives Although behavior modification messages are central to primary prevention programs for heart disease, they are also beneficial in addressing secondary prevention goals, and to be effective, messages must reach beyond standard lifestyle modification. For example, significant public health benefit may be derived through campaigns that address symptom recognition and the importance of timely treatment. In brainstorming bold next steps for addressing heart disease symptoms in women, one summit breakout group suggested that a public service campaign be


created to educate women about the seriousness of heart disease symptoms and the need to seek medical help when they experience symptoms. Subsequent to the summit, the US Department of Health and Human Services has done just that with its Make the Call. Don't Miss a Beat campaign. 34 Launched in early 2011, this national public education campaign aims to educate, engage, and empower women and their families to learn the 7 most common symptoms of a MI and encourage them to call 911 as soon as those symptoms are identified. The campaign's messages are also available in Spanish and through multiple social media channels. The effectiveness of this program will depend on reaching the intended audience and on the relevance of the message to women. Summit participants also recommended that a parallel educational campaign be developed and be directed toward primary care providers, emergency department personnel, emergency medical technicians, and other medical first responders to improve the recognition of heart disease symptoms and the concomitant intervention and treatment of women by health care professionals. The need for such education is underscored by the findings of a retrospective cohort study of nearly 6,000 patients with suspected heart-related symptoms, in 1 county in southern United States. In this study, women had 50% greater likelihood of being delayed in the emergency medical setting as compared with men. 35 Incorporating professional education into the public service campaign could help mitigate the frustration and poor outcomes that may arise when women present for care after following the guidelines outlined in the symptom education program only to be evaluated by providers who dismiss their symptoms, do not evaluate them for possible ACS, or otherwise delay their appropriate emergency cardiac care.

Focus area 3: closing the survival gap Presenters and panelists reviewed research documenting sex-based differences among individuals who experience ACS. Women with ACS are more likely than men to have nonobstructive coronary artery disease. 36 Women are less likely to undergo cardiac catheterization and revascularization procedures 37,38 or to receive other evidence-based therapies such as reperfusion therapy 37 and early aspirin or β-blocker treatment. 38 They are at higher risk for receiving overdoses of antiplatelet and antithrombin agents 39 and are also at higher risk for bleeding if they have had a non–ST-segment elevation ACS. 40 Cardiac rehabilitation referral and dropout rates are highest in women, 41 particularly in younger women and those with high scores on depression and anxiety scales. 42 Data such as these yielded more questions than answers (Table I). Summit participants suggested that a priority target for action should be a focus on improving women's

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Table I. Unanswered questions generated by summit participants How do we create effective public policies to increase the impact of public awareness or community-based heart disease prevention programs? Why do women experience a greater rate of procedural-related complications for diagnosis and treatment of CVD? What are the relative contributions of bias, sex differences in anatomy and physiology, lack of sex-specific evidence-based guidance for optimal procedure selection, and other factors? What are optimal rates of diagnostic and therapeutic procedures in women? Can outcome disparities be solved simply by increasing the rates of interventions in women, or is sex-based tailoring of procedures more effective in improving outcomes, a process that may or may not translate to “equity” or an increased rate of procedures in women? Are there psychosocial issues (eg, improving social support or reducing psychosocial stressors) that, if modified, could affect outcomes of cardiac rehabilitation in women?

modifiable risk factors for heart disease. The goals for risk factor reduction would optimally include advocacy, partnerships with businesses, research, and training of professionals.

Advocacy efforts Although legislators and public health professionals cannot eradicate heart disease through regulation alone, they can attempt to implement a behavioral economics model. Through a behavioral economics model, health improvement would become part of life, and communities—by way of public policy and broad-based regulations —would provide incentives for actions that are good for health. In time, poor lifestyle choices would become culturally unacceptable. Partnerships with businesses Corporations can be enlisted in the broad-based effort to reduce women's risk factors for heart disease. For example, in conceptualizing systemic improvements in community health, food and beverage manufacturers could submit ideas about what fundamental changes can be made in the way women eat. Under pressure from public health advocates, some manufacturers have already made changes in products to reduce sodium and trans fats and should be supported in these efforts. Undoubtedly, a business model must be created to justify corporations' buy-in and ensure that the initiatives maintain acceptable profits. Partnerships with communities Stakeholders dedicated to improving women's heart health must work with communities to set standards for promoting change. In some cases, communities will only be able to use currently available resources to help the public modify risk factors (eg, opening gymnasiums in inner-city public schools after hours to give people a safe place to be physically active). In other cases,

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communities may be able to make more comprehensive changes to the built environment (eg, designing buildings with central and well-marked stairwells or creating or improving the safety of walking and running paths).

Research directions Although studies have provided data about stages of behavior change and what features constitute successful behavior-change models, researchers still know little about precisely what engages women in activating change in their lives. When researchers complete the investigations that make this information available, the information must then be effectively disseminated to communities. Training professionals Mitigating prevalent disease requires more tailored, individualized assessment and interventions among at-risk populations; preventing heart disease in women is no exception. To accomplish this goal, health professionals must become better educated about effective risk assessment, risk management, and follow-up. Such training should also include curricula for midlevel providers.

Focus area 4: patient-provider connections Psychosocial status is closely related to patients' adherence with providers' therapeutic recommendations. Addressing barriers related to depression, anxiety, and inadequate social support will be critical to improve effective patient-provider communication and relationships. It is important to evaluate the “noncompliant patient” from a holistic standpoint. These individuals may have numerous risk factors including tobacco use and often have limited education, poor access to community resources, low income, and other underlying barriers and social strains such as depression, job or marital stress, lack of a supportive network and family/social support, and myriad family responsibilities (including demanding caregiving roles). These are layered upon the complexities involved in caring for patients over time and patientprovider negotiations and recommendations for pharmacologic therapy, rehabilitation, and lifestyle changes.

Depression and heart disease Women diagnosed with heart disease have more depression, anxiety, stress, and reduced health-related quality of life than those without heart disease and men with heart disease. 43,44 Women with depressive symptoms after MI or diagnosis of heart failure have elevated morbidity and mortality and rates of rehospitalization. Younger women and those with a prior diagnosis of depression are particularly at risk. 45 The bidirectional relationship between depression and anxiety and heart disease is indisputable, but the mechanism(s) and clinical


implications remain obscure. 46 However, both cardiac rehabilitation and moderate physical activity reduce depressive symptoms, 47,48 and recent research indicates that there may be an additional mortality benefit from sex-tailored cardiac rehabilitation. 49

Job and marital strain In a study involving N20,000 female registered nurses, 50 low job control, high job demand, and low work-related social support correlated with poor functional status at baseline and at 4-year follow-up. This association occurred independent of age, body mass index, comorbidities, alcohol consumption, smoking status, education level, physical activity level, employment status, marital status, or the presence of a confidante. Among female heart disease patients aged 30 to 65 years who had a spouse or were cohabitating with a partner, marital stress was associated with a nearly 3-fold risk for a recurrent coronary event. 51 Lack of social network/social support Women with low social support have increased risk factors for and prevalence of coronary artery disease and a greater likelihood of experiencing a cardiovascular event and death. 52 During 2.3 years of follow-up, women with suspected coronary disease who had low social support had nearly double the mortality rate of those with high social support. 52 In the Enhancing Recovery in Coronary Heart Disease trial, 53 low perceived social support conferred a 13% higher risk in death or nonfatal MI. Impact of caregiving Through its impact on health—namely, increased stress, exhaustion, less time for self, sleep disturbances, and lack of time for other friends or family—caregiving can be a potential barrier to heart health. In 1 investigation, 3 most of the female participants (51%) cited family and caregiving responsibilities as a barrier to their taking action to prevent heart disease. Caring for grandchildren in particular has been shown to be detrimental to women's heart health. In the Nurses' Health Study, 54 researchers found that women who cared for non-ill children ≥21 hours per week or who cared for non-ill grandchildren ≥9 hours per week had an increased risk of CHD compared with women who did no caregiving. The key issues inherent in addressing the sources of psychosocial stress in women with heart disease include (1) helping clinicians better ascertain psychosocial stress factors in their patients, particularly to help address barriers to secondary prevention of heart disease in women; (2) ensuring that patients are physically, emotionally, and logistically supported after hospitalization for a cardiac event; and (3) reducing the workload of


being a female patient with heart disease by making outpatient care less fragmented. In brainstorming ways to address these challenges, summit participants suggested developing women-centered care models for heart disease (ie, bringing care to places that female patients are most likely to go). Primary and secondary prevention messages and education, for example, could be administered in obstetrics/ gynecology, primary care, and pharmacy settings, assuming that these providers receive adequate training. Follow-up telephone consultation, help lines, and Internet-based peer-to-peer support groups could also be helpful in guiding female patients toward better adherence to cardiac rehabilitation and secondary prevention programs.

Discussion Recommended strategies for the bold next steps During the presentations and discussions on day 1 of the summit, participants and presenters acknowledged the progress made toward increasing public awareness, improving treatment, and improving primary and secondary prevention to reduce the morbidity and mortality of heart disease in women. Through the multidisciplinary dialogue, key challenges encountered by researchers, public health professionals, providers, health care consumers, and obstacles to achieving a reduction in the untimely deaths in women with heart disease were identified. To address these challenges and obstacles, summit participants identified bold next steps: strategies designed to dissolve barriers to and increase effectiveness of cardiovascular care for women. These are listed in Table II. Through interactive breakout sessions, summit participants elaborated on key strategies and practical solutions for raising community awareness and increasing primary and secondary prevention efforts in this area. Although these ideas were action oriented, attendees acknowledged that strategies involved in implementing such solutions would be complex. Societal, provider, and patient misperceptions of the disease persist, and a lack of evidence-based information continues to hamper progress in identifying risk factors, creating appropriate protocols for diagnosis and treatment, and improving care outcomes. Common threads throughout all of the summit recommendations included the need for more standardized data collection and that mandatory reporting of variables should go beyond sex and sex-based factors to include race and age, at a minimum. Participants agreed that success will require enhanced recognition of heart disease and its risk in the clinical setting and increased heart disease awareness among women who are medically underserved or economically disadvantaged.

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Table II. Proposed strategies for bold next steps Research Design all research trials and initiatives to consider and illuminate potential sex-based differences. Mandate reporting of sex-specific data and results. Increase recruitment of underserved and high-risk populations to clinical trials. Focus research on increasing engagement in health-promoting behaviors. Analyze existing data sets to evaluate sex-related cardiovascular issues. Characterize presenting symptoms of ACS and other cardiovascular conditions by standardizing data collection to include not only sex but also race, age, and associated symptoms. Practice Standardize data collection and information sharing via accessible electronic health records. Mandate reporting of sex-based practice data to better detect potential care disparities. Improve recognition and awareness of heart disease symptoms and presentation in women. Develop strategies to address women's physical and psychosocial impairments. Focus on underserved and high-risk women when targeting messages, cardiovascular screenings, and services. Community programming Develop an educational campaign targeting both laypersons and providers to improve recognition and awareness of women's heart disease symptoms and their presentation. Improve community support and resources to address women's physical and psychosocial attributes. Increase engagement, programming, and resources to underserved and high-risk populations. Partner with industry to improve the health of food products and create policies that help improve the food environment. Advocate for public policy that improves both public health and health care for women with heart disease. Increase public health resources and develop policies that promote physical activity and other positive health behaviors. Education Educate health professionals about effective assessment, risk management, treatment, and follow-up of women at risk for and diagnosed with CVD.

Action plan After the summit, an action plan was generated by the summit planning group that includes various priorities and initiatives (Table III). Some of the initiatives focused on best practices in assessment, treatment, and the development and assessment of more effective models of care delivery. However, a greater share of the plan focused on identifying and reducing risk factors and health risk behaviors (eg, tobacco use, sedentary lifestyle, poor dietary practices) and targeting high-risk populations with accessible, inexpensive, effective resources and services to help women adopt healthier lifestyles. The messaging to individuals and diverse populations, policy makers, and the general public regarding cardiovascular risk, risk screening, treatment, and follow-up must be intensified, sharpened, consistent, and coordinated. Efforts must be led by a well-educated and informed interdisciplinary team of health care providers with actively


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Table III. Key priorities and next steps to eliminate untimely deaths in women from heart disease Focus area Community awareness and prevention

Symptom recognition and delays in seeking treatment

Closing the survival gap

Patient-provider connections

Key priorities/next steps 1. Engage national organizations and health care providers to deliver a single consistent message to women on prevention of heart disease. Communication strategies should target women as caregivers and focus on their roles in family and community. 2. Define diverse populations at risk and offer interventions that move beyond building awareness to achieving health behavior change. a. Identify data and resources available through insurers, hospital groups, health care providers, and researchers. b. Conduct data analysis to identify population subgroups. c. Leverage existing health behavior change programs. 3. Create policies and regulations that improve the built environment so healthier lifestyle choices, such as heart-healthy nutrients, freedom from smoke and tobacco use, and physical activity are more safe, convenient, and accessible. 1. Ensure that all public service campaigns for women are racial/ethnically and culturally appropriate and address the following: a. What is a MI? b. Why should one seek early care and not delay? c. Who is at risk for a MI? d. What are the signs and symptoms of a MI? e. Identify and overcome barriers to early care (eg, denial, embarrassment, do not want to burden family, do not want to bother physician or health care professionals). f. Why should one call emergency medical services? 2. Create a standardized cardiovascular symptoms data collection toolkit to better identify the key diagnostic criteria and prodromal symptoms in women of stable angina, unstable angina, nonSTEMI, STEMI, and sudden cardiac death. This should incorporate data on the following: a. Prodromal symptoms b. Acute symptoms (within 48 h) of the event c. Primary symptoms: prodromal and acute d. Ancillary symptoms: prodromal and acute 3. Ensure multidisciplinary approach to education regarding assessment and treatment of women. All providers should assess risks and symptoms consistently. 1. Advocate for policies that support preventive interventions/initiatives for screening and community programs. 2. Facilitate collaboration opportunities between clinicians, educators, the community, and industry to promote awareness of preventive programs/activities. 3. Advocate for research that identifies effective risk assessment/prevention programs and translate that research into practice. 4. Encourage demonstration projects in health promotion/delivery models and partnerships with communities to optimize resource utilization and improve cardiovascular health and outcomes. 1. Engage partners, funders, and other key stakeholders to work to identify best practices in women's cardiovascular care delivery and support pilot projects to test various care models 2. Improve participation in cardiac rehabilitation by addressing key barriers (eg, work, caregiver roles, cultural differences, access, and socioeconomic status). 3. Leverage accountable care organization initiatives. 4. Provide services close to “point-of-life” vs “point-of-care.”

STEMI, ST-segment elevation myocardial infarction.

engaged individuals and activated communities. Results of action on these initiatives could be foundational themes for a future summit. A follow-up summit would ensure that the momentum created among the attendees representing diverse organizations, disciplines, and institutions would continue and that progress could be made to eliminate untimely deaths of women from heart disease.

Conclusions Bold steps will be required to move from the merely incremental improvements to transformative change in women's heart health and heart care. Widespread and

persistent barriers to eliminating disparities such as lack of awareness and symptom recognition, delays in treatment, and ineffective patient-provider connections provide a compelling argument for institution of bold steps to increase research and prevention programming —especially among diverse populations. Development of new models and partnerships to improve quality, accessibility, and delivery of care to women are necessary if we are to decrease cardiovascular mortality in women. The Women's Heart Summit convened an engaged interdisciplinary group of state and national experts and stakeholders who generated actionable ideas and strategies to address the problem of the premature deaths


of women from heart disease. The strategies have been translated into an action plan that is now being implemented by members of the summit planning committee. The outcomes of these efforts could be evaluated and reported to the community and will lay the groundwork for a future follow-up summit, now being contemplated by the planners.

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17.

18.

19.

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Appendix. Minnesota summit sources of conference support Educational grants from the following companies made the summit possible: Abbott Laboratories, North Chicago, Illinois Astellas Pharma Global Development, Inc, Deerfield, Illinois AstraZeneca LP, Wilmington, Delaware Boston Scientific Corp, Natick, Massachusetts Gilead Sciences, Inc, Foster City, California Medtronic, Inc, Minneapolis, Minnesota Pfizer, Inc, New York, New York SonoSite, Inc, Bothell, Washington St. Jude Medical, St. Paul, Minnesota The Medicines Company, Parsippany, New Jersey

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Exhibit support for the summit was provided by the following companies: Abbott Laboratories, North Chicago, Illinois AstraZeneca LP, Wilmington, Delaware Boehringer-Ingelheim, Ridgefield, Connecticut Boston Scientific Corp, Natick, Massachusetts Bristol-Myers Squibb, New York, New York Daiichi Sankyo, Inc, Nihonbashi-honcho, Chuo-ku, Tokyo, Japan Forest Pharmaceuticals, Inc, New York, New York GlaxoSmithKline, Philadelphia, Pennsylvania Lilly, USA, LLC, Indianapolis, Indiana Medtronic, Inc, Minneapolis, Minnesota Merck & Co, Inc, Whitehouse Station, New Jersey Novartis Pharmaceuticals, Basel, Switzerland Sanofi-Aventis, Bridgewater Township, New Jersey St. Jude Medical, St. Paul, Minnesota